MightyWELL Health Plan Accident Application
Underwritten by Philadelphia American
Primary Applicant Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Application Type
New Application
Policy Changes
Requested Effective Date
-
Month
-
Day
Year
Date
Policy Type
Individual
Group
Group or Company information if Premium Payer
Name
Street Address
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Primary Applicant
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
M/F
Date of Birth
-
Month
-
Day
Year
Date
Age
Social Security Number
Height
Weight
Birth State
Primary Applicants Occupation or Job Description
Hazardous Occupations require additional underwriting
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Click next, if no spouse
Spouse Name
First Name
Middle Name
Last Name
Gender
M/F
Date of Birth
-
Month
-
Day
Year
Date
Age
Social Security Number
Height
Weight
Primary Applicants Occupation or Job Description
Hazardous Occupations require additional underwriting
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Click next, if no child(ren)
Click to open child 1 application
First Child's Name
First Name
Middle Name
Last Name
Gender
M/F
Date of Birth
-
Month
-
Day
Year
Date
Age
Social Security Number
Height
Weight
Click to Open Child 2 Application
Second Child's Name
First Name
Middle Name
Last Name
Gender
M/F
Date of Birth
-
Month
-
Day
Year
Date
Age
Social Security Number
Height
Weight
Click to Open Child 3 Application
Third Child's Name
First Name
Middle Name
Last Name
Gender
M/F
Date of Birth
-
Month
-
Day
Year
Date
Age
Social Security Number
Height
Weight
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Plan Selection and Benefit Levels
Minor Accident Benefit
Covers minor accident and expenses that occurs 45 days of accident. NO deductible
Accident Benefit per Event
$2,000 ( Value Plan)
$4,000 ( Preferred & Premier Plans)
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Health Questions
Yes answers may increase premium. Your MightyWELL Representative will advise you of any price increase prior to billing.
Yes
No
1. In the past 12 months, has any person to be insured engaged in any hazardous sport or activities including organized racing, parachuting, rodeo riding, motorcycling, mountain climbing or scuba diving?
2. In the past 3 years, has any person to be insured currently under treatment or has any person to be insured been under treatment for excessive drug or alcohol abuse?
3. Are all persons to be insured ages 19 to 26 years old enrolled as a full time student in an accredited school or college?
4. In the past 12 months, has anyone proposed to be insured been diagnosed with or treated for an injury, disease, or disorder of the back, neck, or a joint by a member of the medical profession?
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MightyWELL Representative
MightyWELL Representative Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Beneficiary
Name
First Name
Last Name
Relationship to insured
Banking Information
Type
Individual
Group Billing
Signature
Clear
Date
-
Month
-
Day
Year
Date
Preview PDF
Submit
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